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93_uj- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR1.00AC AGENCY USE oKy <br /> REPORT BEEN FI.EO 7 <br /> ED YES NO ❑YES ❑.NO j HEREBY C8MTmT HAVE DISTRBII E}TH15 WFORIAA' ALCOR #A TO T E' <br /> RsuTK)N sHawtr off T1 <br /> REPORT TE CASE SHEET OKTHE BACK PA( DFTHIS FORM_ <br /> S .. » TE <br /> NAME OF INOIVIOUAL FILING REPORT � <br /> Z. V�( �9) y68-3 SK S... <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ BOARD <br /> COMPANY OR AGENCY NAME <br /> Q LOCAL AGENCY ❑ OTHER <br /> a ADDRESS <br /> NAME �1F � _�c� CONTACT PERSON — P <br /> d ADDRESS t �� <br /> M M ,LL CA- 9sv 3 <br /> FACILITY NAME(IF APPLICABLE) CKRATOR <br /> grff- fl* <br /> 4 ADDRESS <br /> CA <br /> CROSsST <br /> Seo <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> rgxl- <br /> P W-44-D <br /> zv <br /> uj i GgNAL BDARD � 3 <br /> HONE <br /> 2 r3 (I'M361-sz CPO <br /> In (1) NI 1kbAME / ��++�� QUANTITY LOST(GALLONS) <br /> P_ <br /> 4 o 1 drO 6 O Al ❑ UNKNOWN <br /> coa <br /> �- DATE DISCOVERED HOW DISCOVERED <br /> z INVENTORY CONTROL p SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 9 HE <br /> Y ❑ TANK TEST TANK REMOVAL p OTR <br /> DATE DISCHARGE BEGIN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W p UNKNOWN ❑REMOVE CONTENTS p CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 p REPAIR TANK p CLOSE TANK E FILL IN PLACE p CHANGE PROCEDURE <br /> C3 YES p NO IF YES.DATE j yj 'r p REPLAGE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> F-1 TAW LEAK � UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE p SPILL <br /> p PIPING LEAK ❑ OTHER ❑ CORROSION OTHER <br /> CHECK ONE ONLY <br /> Ex UNDETERMINED ❑ SOILONLY ❑ GROt*IOWATER p DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CACK ONE ONLY <br /> p NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY p POST CLEANUP MONITORING IN PROGRESS <br /> V <br /> ❑ REMEDIATION PLAN p CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) p CLEANUP UNDERWAY U! <br /> CHECK APPROPRIATE ACT1ON(S) <br /> iar�a�ranoerrrat ❑ EXCAVATE 8 DISPOSE(ED) p REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(IT) ` <br /> p ❑ CAP SrrE(CD) ❑ EXCAVATE i TREAT(ET) ❑ PUMP i TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) (^ <br /> Q p CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) �r <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> olu so rlo,� V 6-5 <br /> Lu -i4.&7xoe Aa <br /> 0 F co <br /> r 7A AZ <br /> N8C I <br />